SMLE Internal Medicine 1 — Questions and Answers
Question 1: A 55-year-old male presents with polyuria, polydipsia, and a fasting blood glucose of 9.5 mmol/L on two occasions. What is the most appropriate initial management?
- Insulin glargine
- Lifestyle modification and metformin (Correct answer)
- Sulfonylurea monotherapy
- GLP-1 receptor agonist
Correct answer: Lifestyle modification and metformin
According to SCFHS guidelines aligned with international standards, first-line management of newly diagnosed type 2 diabetes includes lifestyle modifications combined with metformin, which improves insulin sensitivity and has cardiovascular benefits.
Question 2: A 60-year-old patient with a history of atrial fibrillation presents with sudden onset right-sided weakness and aphasia. CT brain shows no haemorrhage. What is the most appropriate immediate intervention?
- IV alteplase within the thrombolytic window (Correct answer)
- Aspirin 300 mg immediately
- Heparin infusion
- Observation and repeat CT in 24 hours
Correct answer: IV alteplase within the thrombolytic window
In acute ischaemic stroke presenting within the thrombolytic window (4.5 hours) with no contraindications and no haemorrhage on CT, IV alteplase is the standard of care for reperfusion therapy.
Question 3: Which autoantibody is most specific for systemic lupus erythematosus (SLE)?
- Anti-nuclear antibody (ANA)
- Anti-double-stranded DNA (anti-dsDNA) (Correct answer)
- Anti-Ro (SSA)
- Rheumatoid factor
Correct answer: Anti-double-stranded DNA (anti-dsDNA)
While ANA is highly sensitive for SLE, anti-dsDNA antibodies are highly specific and correlate with disease activity, particularly lupus nephritis.
Question 4: A 45-year-old woman presents with progressive dyspnoea and a butterfly-shaped infiltrate on chest X-ray. She has a history of mitral stenosis. What is the most likely cause of the radiographic finding?
- Community-acquired pneumonia
- Pulmonary oedema (Correct answer)
- Pulmonary embolism
- Sarcoidosis
Correct answer: Pulmonary oedema
A butterfly or bat-wing pattern on chest X-ray is classic for pulmonary oedema. In a patient with mitral stenosis, elevated left atrial pressure leads to pulmonary venous congestion and transudative pulmonary oedema.
Question 5: A patient with chronic kidney disease stage 4 has a serum potassium of 6.2 mmol/L and peaked T waves on ECG. What is the most urgent first step?
- Oral sodium polystyrene sulfonate
- IV calcium gluconate (Correct answer)
- IV insulin with dextrose
- Urgent haemodialysis
Correct answer: IV calcium gluconate
IV calcium gluconate is the most urgent intervention as it stabilises the cardiac membrane and protects against arrhythmias. It does not lower potassium but buys time for definitive treatment.
Question 6: A 30-year-old male from Riyadh presents with fever, dry cough, and bilateral ground-glass opacities. He works at a camel farm. What is the most likely causative organism?
- Mycobacterium tuberculosis
- Influenza A H1N1
- Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (Correct answer)
- Coxiella burnetii
Correct answer: Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
MERS-CoV is endemic in Saudi Arabia with dromedary camels serving as the primary zoonotic reservoir. Camel farm workers are at high risk. The presentation with fever, cough, and bilateral ground-glass opacities is characteristic.
SMLE Internal Medicine 1
A 55-year-old male presents with polyuria, polydipsia, and a fasting blood glucose of 9.5 mmol/L on two occasions.
What is the most appropriate initial management?